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LANE COUNTY PUBLIC WORKS City Referral Form — Onsite Wastewater (Septic) LAND MANAGEMENT DIVISION 3050 North Delta .Highway, Eugene, OR 97408 This form may be used by City officials within Lane County to inform Lane County when a proposed development, either within the city limits or within the city's UGB, does not have physical and/or legal access to the piped public wastewater system and will therefore need to direct wastewater to an onsite private wastewater (aka, septic) system. In order for a property owner to obtain a septic system permit from the County, the City must first determine that the public wastewater system is not available for connection*. Sanitation repair and alteration permits, and development proposing a new septic system or potential increases of flow to an existing septic system, are required to obtain a septic permit or authorization notice from the County's Sanitation office. Please complete the following form and submit it to Lane County Sanitation staff. PERMIT APPLICANT STATEMENT I have researched and I understand the public wastewater and private on -site septic system options for the proposed development des ribed below. I am requesting approval of a permit or authorization notice from Lane County for: An alteration or repair of the existing septic system (no other construction or development is proposed on the site) ❑ An installation of a new septic system ❑ An authorization to continue to use the existing septic system (no work is proposed to the existing septic system) A complete application, including this form and a copy of the site plan submitted to the City, will be submitted to Lane County. Applicant Name Date ri 2ZZ`; Signature V [e-q SA_k L VA-1\L SECTION 1 (May be filled in by the applicant or by the City official) 1. Applicant Name !!t'LI�t StitLu��A�l�, Mailing Address Zr'I�� City/State/Zip 2. Property Information: Property Owner Name `T1 h�1 aPcU►a�t�� I�C�2-I�ikNE CRf1GC�iT Map (TRS) & Tax Lot Property Address 251$lb-4- Vfl_5O,!5"f IE�u L—kc-Me- I C, 0- - q—f 4�b Z- Telephone (4,;rrI) L3-Z-3�f�3 Email TbW C'U(4'�& # CZtiA 3. The foll win wor is roposed (Please check all applicable boxes): KV _ , T"CN ❑ Afic repair or [alteration ONLY. No building or development work is proposed on the site. ❑ A new ❑ single-family dwelling (SFD) or ❑ duplex An additional/secondary dwelling unit (ADU/SDU) The addition of one or more bedrooms to an existing EISFD, ❑ ADU/SDU, or ❑ duplex An addition to an ❑ SFD, [IADU/SDU, or El duplex. No new bedrooms proposed. A new detached accessory structure or addition to an existing one. Provide use description: A change in land use or building occupancy that may change the sewage flow to an existing septic system. Provide description: ❑ Multi -Family or commercial. Provide description: Is the a development replacement to what was there before? 0 Yes ❑ No proposed p If yes, please describe previous use (including number of bedrooms). WSSA UY R-&PLA6 ThIE; IiCL-bt MtT TA N IL VJ I i N �, IJG�I TATI IL - THTtj& �% 15 tJ o SIEPT L TAMK-